HESI NCLEX-RN FUNDAMENTALS NEWEST 2024
COMPLETE 200 ACTUAL EXAM QUESTIONS WITH
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
AGRADE ASSURED!!
The nurse transcribes the postoperative prescriptions for a client who returns to the unit
following surgery and notes that an antihypertensive medication prescribed
preoperatively is not listed. What action should the nurse take?
✓ Contact the healthcare provider to renew the prescription for the medication.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the healthcare provider if the antihypertensive medication is not included
in the postoperative prescriptions
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
✓ Check the bath water temperature.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature
In completing a client's preoperative routine, the nurse finds that the operative permit is
not signed. The client begins to ask more questions about the surgical procedure. What
action should the nurse take next?
✓ Inform the surgeon the operative permit is not signed and the client has
questions about the surgery.
Rationale:
The surgeon should be informed immediately that the permit is not signed
pg. 1
,A hospitalized client has had difficulty falling asleep for two nights and is becoming
irritable and restless. What action by the nurse is best?
✓ Determine the client's usual bedtime routine and include these rituals in the plan
of care as safety allows.
Rationale:
Including habitual rituals that do not interfere with the client's care or safety may allow
the client to go to sleep faster and increase the quality of care
After the nurse tells an older male client that an IV line needs to be inserted, he
becomes very apprehensive, loudly verbalizing his dislike for all healthcare providers
and nurses. How should the nurse respond?
✓ Calmly reassure the client that the discomfort will be temporary.
Rationale:
The nurse should respond with a calm demeanor (C) to help reduce the client's
apprehension. After responding calmly to the client's apprehension
The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify the placement of the IV access?
✓ Right cephalic vein
Rationale:
The cephalic vein is large and superficial and identifies the anatomical name of the vein
that is accessed, which should be included in the documentation (B). The basilic vein of
the arm is used for IV access, not the brachial vein
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A
comatose client winces and pulls away from a painful stimulus. What action should the
nurse take next?
✓ Document that the client responds to painful stimulus.
Rationale:
The client has demonstrated a purposeful response to pain, which should be
documented as such
pg. 2
,An older male adult who recently began self-administration of insulin calls the nurse
daily to review the steps he needs to take when giving his injection. The nurse assessed
the client's skills during two previous office visits and knows he is capable of giving
himself the daily injection. What response by the nurse is likely to be most helpful in
encouraging the client to assume total responsibility for his daily injections?
✓ "When I have watched you give yourself the injection, you did it correctly."
Rationale:
The nurse needs to focus on the client's positive behaviors, so focusing on the client's
demonstrated ability to self-administer the injection (C) is likely to reinforce his level of
competence without sounding punitive.
The nurse determines that a postoperative client's respiratory rate has increased from
18 breaths/min to 24 breaths/min. Based on this assessment finding, which intervention
is most important for the nurse to implement?
✓ Determine if pain is causing the client's tachypnea.
Rationale:
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea
(increased respiratory rate). Encouraging (A) when the respiratory rate is rising above
normal limits puts the client at risk for further oxygen desaturation.
A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
What action should the nurse take first?
✓ Discuss the importance of personal hygiene during menstruation with the client.
Rationale:
Since a shower is most beneficial for the client in terms of hygiene and mobility, the
client should receive teaching first (D), respecting any personal beliefs, such as cultural
or spiritual values.
When the healthcare provider diagnoses metastatic cancer and recommends a
gastrostomy for an older female client in stable condition, the son tells the nurse that his
mother must not be told the reason for the surgery, because she "can't handle" the
cancer diagnosis. What legal principle is the court most likely to uphold regarding this
client's right to informed consent?
pg. 3
, ✓ If informed consent is withheld from a client, healthcare providers could be found
guilty of negligence.
Rationale:
Healthcare providers may be found guilty of negligence (D), specifically, assault and
battery, if they carry out a treatment without the client's consent. The client's condition is
stable, so (A) is not a valid rationale. Advanced age does not automatically authorize
the son to make all decisions for his mother, and there is no evidence that the client is
mentally incompetent
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
✓ Assess the client's medical record to determine the client's normal bowel pattern.
Rationale:
This client may not routinely have a daily bowel movement, so the nurse should first
assess this client's normal bowel habits before attempting any intervention
When emptying 350 ml of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. What action should the nurse take
next?
✓ Record the amount on the client's fluid output record.
Rationale:
The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output (A), but no additional action is needed
Which client is most likely to be at risk for spiritual distress?
✓ A Roman Catholic woman considering an abortion
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this
decision may place the client at risk for spiritual distress
The nurse teaches the use of a gait belt to a male caregiver whose spouse has right-
sided weakness and needs assistance with ambulation. The caregiver performs a return
pg. 4
COMPLETE 200 ACTUAL EXAM QUESTIONS WITH
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
AGRADE ASSURED!!
The nurse transcribes the postoperative prescriptions for a client who returns to the unit
following surgery and notes that an antihypertensive medication prescribed
preoperatively is not listed. What action should the nurse take?
✓ Contact the healthcare provider to renew the prescription for the medication.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the healthcare provider if the antihypertensive medication is not included
in the postoperative prescriptions
In assisting an older adult client prepare to take a tub bath, which nursing action is most
important?
✓ Check the bath water temperature.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature
In completing a client's preoperative routine, the nurse finds that the operative permit is
not signed. The client begins to ask more questions about the surgical procedure. What
action should the nurse take next?
✓ Inform the surgeon the operative permit is not signed and the client has
questions about the surgery.
Rationale:
The surgeon should be informed immediately that the permit is not signed
pg. 1
,A hospitalized client has had difficulty falling asleep for two nights and is becoming
irritable and restless. What action by the nurse is best?
✓ Determine the client's usual bedtime routine and include these rituals in the plan
of care as safety allows.
Rationale:
Including habitual rituals that do not interfere with the client's care or safety may allow
the client to go to sleep faster and increase the quality of care
After the nurse tells an older male client that an IV line needs to be inserted, he
becomes very apprehensive, loudly verbalizing his dislike for all healthcare providers
and nurses. How should the nurse respond?
✓ Calmly reassure the client that the discomfort will be temporary.
Rationale:
The nurse should respond with a calm demeanor (C) to help reduce the client's
apprehension. After responding calmly to the client's apprehension
The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify the placement of the IV access?
✓ Right cephalic vein
Rationale:
The cephalic vein is large and superficial and identifies the anatomical name of the vein
that is accessed, which should be included in the documentation (B). The basilic vein of
the arm is used for IV access, not the brachial vein
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A
comatose client winces and pulls away from a painful stimulus. What action should the
nurse take next?
✓ Document that the client responds to painful stimulus.
Rationale:
The client has demonstrated a purposeful response to pain, which should be
documented as such
pg. 2
,An older male adult who recently began self-administration of insulin calls the nurse
daily to review the steps he needs to take when giving his injection. The nurse assessed
the client's skills during two previous office visits and knows he is capable of giving
himself the daily injection. What response by the nurse is likely to be most helpful in
encouraging the client to assume total responsibility for his daily injections?
✓ "When I have watched you give yourself the injection, you did it correctly."
Rationale:
The nurse needs to focus on the client's positive behaviors, so focusing on the client's
demonstrated ability to self-administer the injection (C) is likely to reinforce his level of
competence without sounding punitive.
The nurse determines that a postoperative client's respiratory rate has increased from
18 breaths/min to 24 breaths/min. Based on this assessment finding, which intervention
is most important for the nurse to implement?
✓ Determine if pain is causing the client's tachypnea.
Rationale:
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea
(increased respiratory rate). Encouraging (A) when the respiratory rate is rising above
normal limits puts the client at risk for further oxygen desaturation.
A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
What action should the nurse take first?
✓ Discuss the importance of personal hygiene during menstruation with the client.
Rationale:
Since a shower is most beneficial for the client in terms of hygiene and mobility, the
client should receive teaching first (D), respecting any personal beliefs, such as cultural
or spiritual values.
When the healthcare provider diagnoses metastatic cancer and recommends a
gastrostomy for an older female client in stable condition, the son tells the nurse that his
mother must not be told the reason for the surgery, because she "can't handle" the
cancer diagnosis. What legal principle is the court most likely to uphold regarding this
client's right to informed consent?
pg. 3
, ✓ If informed consent is withheld from a client, healthcare providers could be found
guilty of negligence.
Rationale:
Healthcare providers may be found guilty of negligence (D), specifically, assault and
battery, if they carry out a treatment without the client's consent. The client's condition is
stable, so (A) is not a valid rationale. Advanced age does not automatically authorize
the son to make all decisions for his mother, and there is no evidence that the client is
mentally incompetent
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
✓ Assess the client's medical record to determine the client's normal bowel pattern.
Rationale:
This client may not routinely have a daily bowel movement, so the nurse should first
assess this client's normal bowel habits before attempting any intervention
When emptying 350 ml of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. What action should the nurse take
next?
✓ Record the amount on the client's fluid output record.
Rationale:
The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output (A), but no additional action is needed
Which client is most likely to be at risk for spiritual distress?
✓ A Roman Catholic woman considering an abortion
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this
decision may place the client at risk for spiritual distress
The nurse teaches the use of a gait belt to a male caregiver whose spouse has right-
sided weakness and needs assistance with ambulation. The caregiver performs a return
pg. 4
